PTSD: Facing the Monster

The sound of a helicopter hovering above a Boston park snapped Maj. (Dr.) Derek Speten's thoughts from a relaxing day with his family back to a trauma bay in Iraq. For Capt. Kevin Lombardo, the sight of blood on his face in a recurring nightmare convinced him his mind was still struggling to cope with witnessing a deadly rocket attack on a Humvee. Master Sgt. Justin Jordan found himself disassociating for hours and driving 20 mph on an Albuquerque interstate.
Their symptoms and triggers may vary, but all three men were among the many Air Force members who have experienced post-traumatic stress disorder after returning from deployments in Afghanistan and Iraq.

"Something's going to trigger it," said Dr. Speten, commander of the 66th Medical Group Diagnostics and Therapeutics Flight at Hanscom Air Force Base, Mass. "That trigger could be a smell or a sound. You might hear a helicopter or the backfire of a muffler and see somebody jump to the ground and lie there for a second. Other people may laugh and think it's funny, but the thing that's not funny is that person has gone back to their trauma."

When Dr. Speten first saw the two Soldiers who were brought to the Joint Base Balad hospital trauma bay after being hit with an improvised explosive device Feb. 14, 2007, he initially thought his patient's wounds weren't as severe as the other patient's. The Soldier had third-degree burns, but he'd applied tourniquets to his companion's leg to keep him alive until they could reach the trauma bay.

When Dr. Speten looked into his patient's throat, he saw the Soldier was severely burned internally. the doctor's head trauma surgeon decided the burns weren't survivable, so the patient was moved to end-of-life comfort care. While they know they're easing the patient's suffering, playing a role in end-oflife comfort care is usually traumatic for any medical professional, Dr. Speten said.

"It's psychologically devastating to most people who are involved in it because you're in the career field to save people, not to euthanize patients out in the combat zone," he said. "You want to save everybody. The problem you have is you don't get that opportunity all the time. You just have to remind yourself you're not the reason they're there."

Before the patient was moved, he told Dr. Speten he didn't want doctors to cut off his wedding ring. Because the doctor didn't yet know the severity of the injuries, his main concern was the risk of cutting off circulation and losing the finger. This would haunt him later after he returned from Iraq.

"Before I looked into his throat and saw what his airway looked like, I would've thought he was going to come out of that trauma bay," Dr. Speten said. "The guilt factor came in for me when I had to stop him in midsentence. I told him we needed to secure an airway and he could tell me everything once he woke up. The problem was he didn't wake up."

Thirteen months after Dr. Speten treated the IED victim, on March 12, 2008, Captain Lombardo responded to an attack on an armored Suburban near the main gate at Contingency Operating Base Adder in Iraq. The attack killed three of the five Soldiers in the vehicle, but Captain Lombardo, an Air Force security forces officer serving as provost marshal for the base, saved one of the two survivors. He moved Army Sgt. Joel Tavera a safe distance from the truck, put a tourniquet on his leg and talked with him for the next half-hour to keep him conscious.

Later, Captain Lombardo dealt with the aftermath of the attack, including a memorial service for the three Soldiers killed in the explosion. Several months after he'd returned to his home station at Peterson Air Force Base, Colo., he began to feel the emotional repercussions of seeing three comrades die so violently. The captain felt guilty because he wasn't able to save all five soldiers. He knew he was suffering from PTSD symptoms, but he was concerned the stigma would put his security clearance and ultimately his job in jeopardy. Recurring nightmares of blood streaming down his face, explosions and soldiers dying convinced him to get help.

"The smell, sounds, sights, touch and even taste are still there from that day," said Captain Lombardo, now the Security Forces Academy director of operations at Lackland Air Force Base, Texas. "You go from being in Iraq to the normal day-to-day setting on an Air Force base. Physically, I was fine, but I knew I wasn't as mentally sharp as I was."

Recent Air Force efforts to address PTSD include the Virtual Reality Exposure Therapy Application for Post-traumatic Stress, now available at mental health clinics at Andrews, Eglin, Elmendorf, Lackland, Langley, McGuire, Travis and Wright- Patterson Air Force bases. The virtual-reality program addresses the patient's avoidance to re-visit violent and other unpleasant memories from their trauma. In a controlled setting with a therapist's guidance, patients put themselves back among the sights, sounds and smells of the original trauma with either a scene of a foot patrol in an Iraqi city or a Humvee convoy in Afghanistan or Iraq. Therapists can add in sounds of helicopters, explosions and dogs barking and even smells such as burning rubber, body odor, diesel fuel, and weapons firing.

"The intent is to be able to utilize a variety of senses whenever you're doing the exposure," said Dr. Kellie Crowe, director of Wilford Hall Medical Center's PTSD Clinic at Lackland. One of the PTSD clinic's missions is to train psychology interns in PTSD treatment, so they can treat it at their next duty station and in Afghanistan and Iraq, Dr. Crowe said.

"Some people are unwilling or unable to do the imagining part that's necessary," she said. "The virtual reality assists those people in bringing back those senses. Avoidance is the primary symptom that maintains PTSD. This kind of puts it right there in front of them and allows the therapist to work with them to start abating that emotional distress."

Sergeant Jordan's PTSD service dog, an English bulldog named Dallas, helps him fight the avoidance behaviors he's learned are part of his PTSD. Before he became the Air Force Inspection Agency's lead checklist program manager at Kirtland Air Force Base, N.M., the sergeant worked on numerous mortuary affairs cases at Davis-Monthan Air Force Base, Ariz.

"On my last deployment, I sent 71 guys home in a box," he said as Dallas slept at his feet on the floor. "You just have to put it into a place in the back of your brain."

The one death Sergeant Jordan couldn't compartmentalize happened in September 2007 when a friend was killed in a forklift accident on base. He sought help and was treated with a form of rapid eye movement therapy. He thought he'd put his PTSD behind him after he left his mortuary affairs duties for the AFIA assignment, but within months after arriving at Kirtland, he witnessed a shooting at a building just outside the base gate. Two people were killed and four were wounded before the shooter killed himself.

"It reverted me right back to where I was, and the flashbacks were worse," Sergeant Jordan said. "I was driving home 20 mph down the highway because I was positive the tires were going to pop. It seems silly and juvenile, but you could be sitting right next to me and tell me, 'Dude, everything's going to be fine.' It wasn't going to be fine to me. This was about to happen now.

"The overwhelming thing that I think we all have in common is the unwillingness to want to have PTSD. Everyone of us expresses guilt because as young men and women, we're taught to suck it up and quit being less of a man or woman. With PTSD, that's impossible."

Just as the original traumatic events that trigger PTSD and the symptoms vary, each patient responds differently to treatment. The two most common effective types of treatment, according to a number of PTSD experts, are cognitive processing and prolonged exposure therapy. The WHMC PTSD Clinic staff predominantly has used these approaches with the approximately 170 patients who have been treated.

Cognitive processing allows patients to understand how their thoughts about what happened can intensify their symptoms. Often, this helps patients who somehow blame themselves for a traumatic event. Through exposure therapy, patients learn to change how they react to painful memories.

"Both therapies are exposure-based," Dr. Crowe said. "Prolonged exposure has the individual access the memory, both in imagining while in a session with the provider, but also in real life, where they go out and do homework assignments to start re-engaging in things they were avoiding, like restaurants and movie theaters. That allows them to build confidence in reintegrating back into the things they enjoy.

"The face of PTSD has changed so much. PTSD is treatable, and we have evidence-based treatments to support that. Generally, there's not a career impact just from seeking treatment. The career impact comes when the symptoms get out of control. It would be unfortunate for someone to get to that point when there are treatments available."

Sergeant Jordan has found that his PTSD service dog, which was trained through the Paws and Stripes nonprofit organization, helps him curtail his symptoms before they can get out of control. He received permission from the AFIA commander to bring Dallas to work each day. Dallas has her own area near Jordan's desk and will tug on his shirtsleeve several times an hour to keep him from "zoning out."

"She can sense my brain chemistry," Sergeant Jordan said. "When it changes, if I'm having an attack, she'll climb in my lap or bark at me because it scares her. She won't let me stay in that situation. A lot of times, I have to keep her calm, so I can't go to that place."

Both Dr. Speten and Captain Lombardo benefitted from cognitive processing therapy as they gradually accepted their PTSD. With Dr. Speten, the breakthrough came when he found a therapist who'd actually experienced life in a war zone. They also each found something they considered special outside of counseling that had a direct impact on their recovery.

Captain Lombardo built a friendship with the Soldier he saved and found himself inspired by Sergeant Tavera's attitude through his long rehabilitation and numerous surgeries. Through his own therapy, Captain Lombardo learned the blood on his face in his recurring nightmare belonged to Sergeant Tavera. On the day of the attack, a firefighter poured a bottle of saline over his head and hands to wash blood from his face after the sergeant was taken from the scene.

"His inspiration and fight made me realize I needed to stop second guessing myself for that day," Captain Lombardo said. "Obviously, you have that line with officer and enlisted. The line's still there with us, but it merged a lot on March 12, 2008, just as the line did between Army and Air Force. He's my new wingman, and I'm hopefully his battle buddy now."

Dr. Speten took the wingman concept to a new level after losing his patient in the Balad trauma bay. When he learned the Soldier had been an avid runner who dreamed of running the Boston Marathon, Dr. Speten decided to run the race in his honor. The doctor trained for more than a year and competed in seven smaller marathons before he finished the Boston Marathon in April 2010. Whenever training became tough, he thought of the Soldier who'd not only endured a horrific attack before succumbing to his injuries, but helped save the life of his companion by applying tourniquets to his partially severed leg.

"Whenever I thought about quitting, I just thought about what this person went through," Dr. Speten said. "Then, [my discomfort] became almost insignificant. It actually made me feel better and I think it was part of the healing process."

After Dr. Speten completed the race, he mailed his Boston Marathon jersey, T-shirt and medal to the Soldier's family. He continues to run races in honor of fallen service members and often runs with his 5-yearold son in a stroller in some of the smaller events. He believes this also has helped his recovery.

"Whenever you get deployed, your family's on the back burner, and when you come back, it's nice to be able to do something that allows you to be involved with them," Speten said. "He doesn't need to know why right now. He understands that we run, and we'll give the medals to people who are deserving of them. Every time we do this, it gets people out there to know that there are people still coming back. These are people who had goals and dreams, and they're not just going to go away. Just because that person is no longer here to compete it doesn't mean somebody else can't pick up the torch and carry it for them."

One thing Airmen returning home from deployments can learn from stories like those of Dr. Speten, Captain Lombardo and Sergeant Jordan is to be proactive about their own treatment. Active-duty members can request an evaluation at their mental health clinic and have rights to confidentiality as long as they do not pose a threat of injury to themselves or others, Dr. Crowe said.

Simply because Airmen haven't identified symptoms yet doesn't mean they escaped unscathed from trauma they experienced or witnessed. The worst thing they can do is to try to hide their challenges for fear of losing their career, family and friends. After finding the help they needed, Captain Lombardo found peace when he learned the source of the blood in his disturbing dreams and Dr. Speten is no longer afraid of helicopters.

"It's a scar," Dr. Speten said. "Somebody's put holes in me, and you can't cover them up. The holes are still visible, but it doesn't affect how I live the rest of my life."

Scrambled on Sept. 11: F-15 Pilot Saw All Three Axioms of a Fighter Pilot at Work as He Patrolled the Skies

The voice of a Boston Center controller came across Maj. Martin Richard’s F-15 Eagle radio on the morning of Sept. 11, 2001.
“There’s something going on in New York,” the controller said. “I think you guys need to get back to your base.”
Richard confirmed what the controller told him on his squadron operations frequency, and soon his radio was buzzing with communications.
“It sounds like we are at war,” Richard said to his wingman as he turned his formation of F-15s from the Whiskey 105 training area over the Atlantic Ocean southeast of Long Island, N.Y., and headed back to Otis Air National Guard Base, Mass.
As a 102nd Fighter Wing pilot, Richard was no stranger to working alerts. The wing at Otis ANGB under Air Combat Command had been on alert for more than 35 years and worked closely with the Northeast Aerospace Defense Command and the Northeast Air Defense Sector, now the Eastern Air Defense Sector. During the Cold War, F-15s from Otis were regularly sent to intercept and escort Soviet bombers that drifted up and down the East Coast. Since the Cold War, they were used mainly for drug interdiction missions. The last three scrambles Richard responded to were for a U.S. Coast Guard jet, Navy destroyer and a fish-spotting airplane.
On Sept. 11, Richard was on his way to a routine Defensive Counter Air Mission in the Whiskey 105 area. Instead, his new orders were to intercept and identify aircraft above New York, and if they didn’t respond, be prepared to shoot down.
“I flew for seven hours, but it seemed like I flew for 45 minutes,” Richard said. “What I remember most is the picture of arriving over New York and having the whole lower Manhattan covered in smoke and haze, and thinking that we thought the towers had fallen over on their side, and there had been massive casualties. For the next six or seven hours, we were just running intercepts on planes and helicopters they needed to identify.”
Richard, now a lieutenant colonel and chief of combat operations for the 102nd Air Operations Group at Otis, included many of his observations of Sept. 11 in his business leadership book, “Scrambled – The Secrets of High Pressure Leadership I Used on Sept. 11, 2001. The recently released 10-year edition of Richard’s book includes a forward by 9/11 witness Gil Sanborn, who was nearby in World Financial Center 3 during the World Trade Center attacks and is now an investment banker in New York.
He also shares how the three axioms of the fighter pilot were put into action above the nation’s skies that day. Those axioms are: Speed is Life, Lose Sight, Lose Fight, and Check Six.
“With the first one, our mission was to get airborne as quickly as possible,” Richard said. “I remember thinking at the time I didn’t know what I was going to be able to do, but I really just wanted to get up in the air because that’s where I needed to be.
“With Lose Sight, Lose Fight, there was just so much going on that morning, and we had so many bogus intelligence reports that it really made us focus on our objective at hand, which was regaining air superiority over the country. Check Six was just that mutual support thing. We really worked together well, even though we were in different aircraft, to sort of get the big picture, which was what NORAD needed from us.”
For the first five years after 9/11, Richard wouldn’t look at anything related to the terror attacks. He didn’t even learn until after the fifth anniversary that he lost a colleague at United Airlines that day. Now that 10 years have passed, he is mostly concerned that Americans don’t forget what happened a decade ago, and for the troops still in harm’s way. He also thinks back to his thoughts when the fighter pilots were told they needed to be ready to “take further action” if the pilot didn’t respond after they were intercepted.
“We all knew what that meant,” Richard said. “I can remember vividly thinking I’d been in combat before, but I didn’t want to do what they were asking me to do. But when I got to Manhattan and saw the destruction, a switch flipped inside me, and I told myself, ‘You have to now. You don’t have a choice. This has to stop. Period.”

Spotting the Sun New England Observatory Analysts Have Their Eyes and Radios on Solar Weather

A dreamcatcher marks the gravesite of the chief, or sagamore, of the Agawams across from the Sagamore Hill Radio Solar Observatory in Hamilton, Mass. Local legend states that youths desecrated Masconomet's gravesite a few years after his burial in 1655 and Native Americans believed the chief's spirit roamed the coastal New England area until a special ceremony was held in 1993.

Much like Masconomet was believed to keep watch over his people, solar analysts at the Sagamore Hill observatory keep their eyes and antennas focused on the sun to protect astronauts, American troops and communications from potentially damaging solar activity. A powerful solar flare could release deadly radiation and require astronauts in the International Space Station to stay in a protected part of the station. In a war zone on Earth, a communications disruption might put troops at risk during an operation. Solar analysts watch the sun for threats to communications that few people even consider in our technological world.

"No one is ever really interested in the weather until they are impacted by the weather," said Tech. Sgt. Donald R. Milliman, NCO in charge of operations. "The same is true of solar weather." Solar analysts such as Staff Sgt. Wesley R. Magnus monitor the sun's radio emissions with a radio telescope that uses three parabolic antennas of 28 feet, 8 feet and 3 feet in diameter, along with fixed semi-bicone and tracking antennas. Analysts detect and identify any sudden increases in the sun's radio energy that show solar flares and other activities that could disrupt communications.

The solar alerts provided to the Air Force Weather Agency's Space Weather Operations Center protect national space programs, including Space Shuttle operations, military surveillance and communications systems. When the radio detects an event, the analyst has two minutes to send the alert to AFWA at Offutt Air Force Base, Neb. Analysts at this New England outpost are anxiously waiting because the sun has been quiet in recent years.

"Sometimes the job is like a little child waiting for the first snowflakes of the year," said Sergeant Magnus. "It's about the anticipation and the waiting for something to start happening, but once it does, the go-go is a rush."

Anyone working at the observatory is no stranger to snowflakes. Snowfall and other winter weather are elements the Sagamore Hill's four sister solar observatory facilities in the Radio Solar Telescope Network don't face. The other sites are located in much warmer climates. "The Radar Site," as some locals call the observatory, is located in two buildings on a 32-acre tract of land on the steep Sagamore Hill near the New England coastal communities of Gloucester, Ipswich and Essex. The nine-person staff deals with up to 60 inches of snow a year, not to mention storms the locals call "nor'easters" and "Alberta Clippers." Sometimes, a few inches of snow might fall on Hanscom Air Force Base, 32 miles away, while Sagamore Hill could receive a foot.

Just getting to work in a winter storm is hazardous, with the ice-covered road leading up the steep hill. Two staff members had automobile accidents in the past couple of years. One person was hospitalized after a collision with a snowplow at the bottom of the hill. During the worst storms, all they can do is park at the bottom of the hill and make the half-mile trip to the building on foot. But, because someone has to watch the sun no matter what the conditions are on Earth, one of the solar analysts sometimes spends the night when a particularly bad storm is expected. During the winter, the job includes shoveling and brushing snow from the antennas and constantly monitoring the weather for heavy snowfall.

"The one thing that's definitely unique for this site is we are the only cold weather solar site," Sergeant Milliman said. "All of the other sites are in more tropical weather environments where the only thing they really have to deal with is high rain. Here, we actually deal with high winds, ice and snow, as well as heavy rain. I think it's one of the things that makes our site unique."

The observatory's location itself is crucial to its mission to get the best possible view of the sun at its highest point in the middle of the day. The Air Force Cambridge Research Lab chose the site in 1955 because of its elevation and location in the most eastern part of the United States near the Atlantic Ocean.

"One of the main reasons we sit on top of a hill, rather than flat land, is the nice view we have of the sun," Sergeant Milliman said. "Believe it or not, our location is perfect because we are somewhat protected from the elements. The tree lines protect us from the snow, except for when we get nor'easters."

Solar analysts account for only 12 to 15 of the several thousand weather specialists Air Force-wide. So, a position at one of the solar sites is somewhat of a dream job for many in the career field. Staff Sgt. Heath G. King wasn't one of those who yearned to be a weather forecaster, much less a solar analyst. Hurricanes made the Orlando, Fla., native tired of any kind of weather. As luck would have it, Sergeant King was selected as a forecaster, and after assignments at Shaw AFB, S.C., and in Korea, he found himself at the observatory in 2005.

"I came here with a complete clean slate, as far as knowledge of the general layers of the sun," Sergeant King said. "In terms of solar flares, sunspots and other activities on the sun, I learned all of that on the spot through a lot of on-the-job training, trial and error, as well as some interaction with more seasoned analysts who were here before me. I also did a lot of exploration on the Internet."

Much of the learning process came on one day--Dec. 6, 2006--a day Sergeant King expected to be another quiet one like most of the days since he arrived at the observatory.

"The analyst I was relieving told me everything was quiet. Nothing's going to happen on the sun today," he said. "About 30 minutes later, all of the alarms were going off, we were getting updates from all of the other observatories and I was trying to monitor all three computers at one time."

The intense solar flare that day, sent a tsunami-like shockwave across the visible face of the sun and caused serious disruptions in Global Positioning Systems. Solar bursts begin with a flare that sends high-energy electrons into the atmosphere. This produces radio waves that disrupt frequencies used by navigational systems.

"Primarily, the impact we're most concerned with is on satellites and the space station," Sergeant Magnus said. "These frequencies not only affect the satellites, but all ground-to-plane communications, and anything electronic that sends and receives information. For a warfighter's mission, this can affect anything electronic, including GPS systems and shortwave radios."

Sun-watchers saw little solar activity in recent years. Each solar life cycle, an 11-year period that observers note by the number and location of visible sunspots, includes periods of solar maximum and solar minimum. These are periods that indicate the frequency of solar activity. Solar experts called the current solar minimum one of the lowest on record. In 2008, no sunspots appeared in 266 days, the lowest number since there were 311 spotless days in 1913. As of March 31, 2009, sunspots showed on only 12 of the first 90 days of the year. However, solar weather experts expect the number to increase in the next few years, with the National Oceanic Atmospheric Administration predicting the next solar maximum in May 2013.

"When we do hit solar max, we will be ready," Sergeant Magnus said.

Tech. Sgt. Julia F. Hagen is eager for the next solar maximum cycle. Unlike most of her co-workers, Sergeant Hagen worked at other solar sites. She trained at the Holloman Air Force Base, N.M., optical solar site in 2007 before working as a solar analyst at the site in Learmonth, Australia.

"It was interesting to see both sides of solar observing at both optical and radio sites, sites, but unfortunately it's all been during solar minimum," Sergeant Hagen said. "I think it's going to be really busy and a lot more exciting during solar maximum. We will really have to be on our toes sending out messages, especially when the Space Shuttle goes up."

Information gathered by these analysts is primarily intended for the AFWA, whose staff members then pass on alerts to NASA, NOAA, United States Strategic Command, Air Force Space Command and other high-priority programs. Their data often finds a place on the Internet with research by universities and special interest groups. Unlike many of the groups that use the information for research into issues such as climate change and global warming, Air Force solar analysts are more interested in the immediate impact of solar weather.

"Just as weather forecasters are concerned primarily with day-today forecasts for flying missions, we're concerned with what's going on in the sun right now, what is going to happen tomorrow, and what has recently happened," Sergeant Magnus said. "Some of the researchers who gather our messages and analyze our data are more concerned with the long-term effects of these solar cycles and how they affect our environment."

Sagamore Hill's observatory is scheduled to automate by 2015. When that happens, solar data transmits directly to the AFWA, at Offutt AFB, Neb. From Offutt. Analysts there can pull up data from any solar observatory.

"Once they are fully automated, they will be building an essential hub at the AFWA," said Staff Sgt. Stephen S. Ensminger, assistant NCO in charge of maintenance. "The analyst will actually [have] remote access to data from anywhere in the world from this site or any other site."

The observatory's remote spot on Sagamore Hill, about 30 miles from Hanscom AFB, requires the staff to take care of its own facility. Sergeant Ensminger, Master Sgt. Yolanda Hernandez, NCO in charge of maintenance, and training supervisor Daniel Holmes are responsible for all facility maintenance, which is sometimes a challenge, considering the age of the equipment.

"Some of the parts are so old, they don't even make them anymore," Sergeant Hernandez said. "As things deteriorate over time, getting replacement parts has been a real challenge. We have to do whatever it takes to keep the equipment running."

Maintenance includes talking daily to solar analysts about how equipment is working, calibrating radios, weekly inspections and monthly equipment testing. The age of the equipment means maintainers must have a good handle on how it's working, from the antennas to the radios.

"It's kind of like having the old dial radio in your car," Sergeant Ensminger said. "You had to track it just right to get the station to come in. That's kind of how these old radios are. There is a bit of finesse that goes into tuning them."

The facility is the network's prototype solar radio site, where maintenance specialists go before they report at another site. Holmes, who leads the specialists through two weeks of initial training, takes his responsibilities seriously.

"I personally feel the importance of our radios grows every time someone puts something into space," he said. "The more satellites, vehicles and people we have up there, the more important is the job we do here. The whole world depends on us for the accuracy of their measurements and I take that very seriously."

The significance of the sacred gravesite, clearly visible from inside the Sagamore site's fence, isn't lost on the staff. Just as Masconomet's spirit watched over the Agawam people, according to Native American legend, Space Shuttle crews and combatant commanders can trust their communications capabilities because someone is keeping watch for them.